A presentation by Brian D Sites at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
4. Objectives
• Define the origins of the liberal opioid
prescribing policies
• Summarize the crisis of diversion,
addiction, abuse
• Establish the connection between
escalating utilization and morbidity
• Display public health data regarding
efficacy of opioid therapy
5. “Could have been, would have
been, and should have been
are always undefeated.”
-Coach Jim Harbaugh
6. Pain, pre-90’s
• Painkillers are addictive!
• Newborns and the elderly don’t experience
as much pain
• Pain builds character
• Pain is part of the human experience
• Opioids are for cancer patients
• Pain is subjective, therefore questionable
7. Pain, 1990’s - present
• Painkillers are addictive! No, they’re not
• Newborns and the elderly don’t experience as much pain
Everyone has pain
• Pain builds character Pain has no purpose
• Pain is part of the human experience Suffering should
be avoided at all costs
• Opioids are for cancer patients Opioids are suitable
for many people in pain
• Pain is subjective Subjective reports should be
accepted at face value
8.
9. Striking Statistics
• 100 million Americans have
chronic/acute pain
• 635 billion dollar price tag in treatment
and lost productive
• 80% of cancer pain patients report
under treatment of pain
Institute of Medicine
10. “I’m shocked and surprised at the
magnitude of the problem”
-Dr. Perry Fine, President of the American
Academy of Pain Medicine
11. Why improve pain
management?
• Improve activities of daily living
• Reduce disability
• Increase ability to have employment
• Improve wound healing and
postoperative recovery
American Pain Society
13. • largest integrated
health system serving
8.3 million veterans
• Coined the phrase
(later trademarked by
APS)
• Enacted a national
strategy to ensure that
pain is routinely
assessed using a 0-to-
10 Numeric Rating
Scale (NRS).
Veteran’s Health
System
15. “The current system might just kill you. Many doctors,
in order to get high ratings (and a higher salary),
overprescribe and overtest, just to “satisfy” patients,
who probably aren’t qualified to judge their care. And
there’s a financial cost, as flawed survey methods and
the decisions they induce, produce billions more in
waste. It’s a case of good intentions gone badly awry–
and it’s only getting worse.”
Kai Falkenberg
16. Comments based on
Fenton et al
• If you had “High Satisfaction” with your
care compared to “Low Satisfaction:,
you had 26% increase in odds of death!
• Based on almost 60,000 patients from
the MEPS database.
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization,
Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405-411.
23. • “Network of national organizations and
researchers with financial connections to the
makers of narcotic painkillers…helped create a
body of dubious information favoring opioids
that can be found in prescribing guidelines,
patient literature, position statements, books
and doctor education courses.”
26. Are opioid users
getting healthier?
• No data supporting any improvements
in meaningful outcome metrics such as
reductions in chronic pain, hospital re-
admissions, death, etc
28. This paper documents a marked
increase in the all-cause mortality of
middle-aged white non-Hispanic men
and women in the United States between
1999 and 2013. This change reversed
decades of progress in mortality and was
unique to the United States
29. Health and disability 2000-2010
Year Year
Opioid users No opioids
Remember, anticipated improvement in these
areas was the intellectual foundation for the
liberalization of opioid prescribing policies
30. Key basic tenants are
wrong
Slide from Dr. Andrew Kolodny, Physicians for Responsibility Opioid Prescribing, November 2012, at
http://www.slideshare.net/grouphealth/the-opioid-analgesic-epidemic-how-it-happened#btnNext
In medical school we were taught DON’T WORRY
about addiction if opioids are being given for pain
31. Slide from Dr. Andrew Kolodny, Physicians for Responsibility Opioid Prescribing, November 2012, at
http://www.slideshare.net/grouphealth/the-opioid-analgesic-epidemic-how-it-happened#btnNext
“Although there were 11,882 patients who
received at least one narcotic preparation,
there were only four cases of reasonably well
documented addiction in patients who had no
history of addiction”
32. Conclusions
• Social Policy Changes dramatically
increased opioid prescribing in the US
• This increase in utilization and
expenditures is correlated to epidemic
levels of morbidity and mortality
• There are likely serious conflicts of
interest
• Opioid users on a public health level
are not getting healthier
• It is time to re-think our pain policies
Editor's Notes
The world took a tough love stance towards pain before our generation.
Mastering pain as part of self-actualization
The dominant cultural was
Sometime in the last 30 years, in the context of the shift from paternalistic care to patient-centered care, the story changed
Humans have a fundamental right to avoid pain and be free from physical suffering
In the late 90’s the VA caught on and implemented a national comprehensive pain management strategy.
They specifically credited the American Pain Society in their set of guidelines, and commended the American pain society for making pain a vital sign.
Vital signs are taken seriously, quotes the VA; if pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly.
but this year they crack the top-20, edging out storied families like the Bushes, Mellons and Rockefellers.
Despite initial claims to the contrary, it has become quite clear that increased use = increased availability = increase abuse and death and disability from opiate related harms.
The reference cited is one that informs the way we present opiates to patients – even today I hear it all the time, from nurses, physicians, res, etc. “We think that patients who are in pain don’t develop addictions to opiates.”
Somehow this idea fit our mental model of a patient in pain who is incapable of becoming addicted or dependent on opiates.
From Savage Article:
Some studies suggest that a relatively high percentage of persons treated for opioid addiction first took the drugs in the course of pain treatment. For example, a recent study (Passik et al., 2006a) found that 47 percent (51 of 109) of persons presenting for treatment of oxycodone addiction had their first exposure to opioids through a prescription for pain, and 31 percent of this subgroup had prior histories of problems with alcohol or another substance. This study did not comment on the participants’ biogenetic risks as reflected in their family histories of addiction and thus shed no light on whether these apparent de novo addictions occurred in the presence or absence of identifiable biogenetic risk. No case reports have been identified of patients with no known family or personal risk factors presenting with de novo addiction to opioids related to use of prescription opioids for pain, though it certainly may occur.
The reference cited is one that informs the way we present opiates to patients – even today I hear it all the time, from nurses, physicians, res, etc. “We think that patients who are in pain don’t develop addictions to opiates.”
Somehow this idea fit our mental model of a patient in pain who is incapable of becoming addicted or dependent on opiates.
JAMA cited !!!!